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Endoscopy 2021; 53(04): 383-391
DOI: 10.1055/a-1243-0379
Original article

Incomplete endoscopic resection of colorectal polyps: a prospective quality assurance study

Ina B. Pedersen
1   Department of Medicine, Sorlandet Hospital Kristiansand, Kristiansand, Norway
2   Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
,
Michael Bretthauer
2   Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
3   Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
,
Mette Kalager
2   Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
3   Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
,
Magnus Løberg
2   Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
3   Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
,
Geir Hoff
4   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
5   Department of Medicine, Telemark Hospital Skien, Skien, Norway
,
Senaria Matapour
6   Department of Medicine, Vestre Viken Hospital Trust, Gjettum, Norway
,
Silje Hugin
6   Department of Medicine, Vestre Viken Hospital Trust, Gjettum, Norway
,
Svein O. Frigstad
6   Department of Medicine, Vestre Viken Hospital Trust, Gjettum, Norway
,
Birgitte Seip
4   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
7   Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway
,
Britta A. Kleist
8   Department of Pathology, Sorlandet Hospital Kristiansand, Norway
,
Leif Løvdal
8   Department of Pathology, Sorlandet Hospital Kristiansand, Norway
,
Edoardo Botteri
4   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
,
Øyvind Holme
1   Department of Medicine, Sorlandet Hospital Kristiansand, Kristiansand, Norway
2   Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
3   Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
4   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
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Referred to by:

Incomplete resection rate: incomplete training, imperfect measuring?Endoscopy 2021; 53(04): 392-393
DOI: 10.1055/a-1290-7696

Referred to by:

Author commentary on Ina B. Pedersen et al.Endoscopy 2021; 53(04): v17-v17
DOI: 10.1055/a-1237-5132

Abstract

Background Endoscopic screening with polypectomy has been shown to reduce colorectal cancer incidence in randomized trials. Incomplete polyp removal and subsequent development of post-colonoscopy cancers may attenuate the effect of screening. This study aimed to quantify the extent of incomplete polyp removal.

Methods We included patients aged 50–75 years with nonpedunculated polyps ≥ 5 mm removed during colonoscopy at four hospitals in Norway. To evaluate completeness of polyp removal, biopsies from the resection margins were obtained after polypectomy. Logistic regression models were fitted to identify factors explaining incomplete resection.

Results 246 patients with 339 polyps underwent polypectomy between January 2015 and June 2017. A total of 12 polyps were excluded due to biopsy electrocautery damage, and 327 polyps in 246 patients (mean age 67 years [range 42–83]; 52 % male) were included in the analysis. Overall, 54 polyps (15.9 %) in 54 patients were incompletely resected. Histological diagnosis of the polyp (sessile serrated lesions vs. adenoma, odds ratio [OR] 10.9, 95 % confidence interval [CI] 3.9–30.1) and polyp location (proximal vs. distal colon, OR 2.8, 95 %CI 1.0–7.7) were independent risk factors for incomplete removal of polyps 5–19 mm. Board-certified endoscopists were not associated with lower rates of incomplete resection compared with trainees (14.0 % vs. 14.2 %), OR 1.0 (95 %CI 0.5–2.1).

Conclusion Incomplete polyp resection was frequent after polypectomy in routine clinical practice. Serrated histology and proximal location were independent risk factors for incomplete resection. The performance of board-certified gastroenterologists was not superior to that of trainees.

Supplementary material



Publication History

Received: 09 December 2019

Accepted: 15 July 2020

Article published online:
22 September 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Holme O, Loberg M, Kalager M. et al. Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: a randomized clinical trial. JAMA 2014; 312: 606-615
    CrossrefPubMedSearch in Google Scholar
  • 2 Atkin WS, Edwards R, Kralj-Hans I. et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624-1633
    CrossrefPubMedSearch in Google Scholar
  • 3 Holme O, Schoen RE, Senore C. et al. Effectiveness of flexible sigmoidoscopy screening in men and women and different age groups: pooled analysis of randomised trials. BMJ 2017; 356: i6673
    CrossrefPubMedSearch in Google Scholar
  • 4 Lin JS, Piper MA, Perdue LA. et al. Screening for colorectal cancer: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016; 315: 2576-2594
    CrossrefPubMedSearch in Google Scholar
  • 5 Farrar WD, Sawhney MS, Nelson DB. et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006; 4: 1259-1264
    CrossrefPubMedSearch in Google Scholar
  • 6 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
    CrossrefPubMedSearch in Google Scholar
  • 7 Robertson DJ, Lieberman DA, Winawer SJ. et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2014; 63: 949-956
    CrossrefPubMedSearch in Google Scholar
  • 8 le Clercq CM, Bouwens MW, Rondagh EJ. et al. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut 2014; 63: 957-963
    CrossrefPubMedSearch in Google Scholar
  • 9 Carter D, Beer-Gabel M, Zbar A. et al. A survey of colonoscopic polypectomy practice amongst Israeli gastroenterologists. Ann Gastroenterol 2013; 26: 135-140
    PubMedSearch in Google Scholar
  • 10 Singh N, Harrison M, Rex DK. A survey of colonoscopic polypectomy practices among clinical gastroenterologists. Gastrointest Endosc 2004; 60: 414-418
    CrossrefPubMedSearch in Google Scholar
  • 11 Pedersen IB, Loberg M, Hoff G. et al. Polypectomy techniques among gastroenterologists in Norway – a nationwide survey. Endosc Int Open 2018; 6: E812-E820
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy – results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80.e71
    CrossrefPubMedSearch in Google Scholar
  • 13 Zhang Q, Gao P, Han B. et al. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc 2018; 87: 733-740
    CrossrefPubMedSearch in Google Scholar
  • 14 Knabe M, Pohl J, Gerges C. et al. Standardized long-term follow-up after endoscopic resection of large, nonpedunculated colorectal lesions: a prospective two-center study. Am J Gastroenterol 2014; 109: 183-189
    CrossrefPubMedSearch in Google Scholar
  • 15 Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc 2018; 87: 837-842
    CrossrefPubMedSearch in Google Scholar
  • 16 Aslan F, Camci M, Alper E. et al. Cold snare polypectomy versus hot snare polypectomy in endoscopic treatment of small polyps. Turk J Gastroenterol 2014; 25: 279-283
    CrossrefPubMedSearch in Google Scholar
  • 17 Kawamura T, Takeuchi Y, Asai S. et al. A comparison of the resection rate for cold and hot snare polypectomy for 4–9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study). Gut 2018; 67: 1950-1957
    CrossrefPubMedSearch in Google Scholar
  • 18 Singh R, Zorron Cheng Tao Pu L, Koay D. et al. Sessile serrated adenoma/polyps: Where are we at in 2016?. World J Gastroenterol 2016; 22: 7754-7759
    CrossrefPubMedSearch in Google Scholar
  • 19 Bettington M, Walker N, Clouston A. et al. The serrated pathway to colorectal carcinoma: current concepts and challenges. Histopathology 2013; 62: 367-386
    CrossrefPubMedSearch in Google Scholar
  • 20 Langner C. Serrated and non-serrated precursor lesions of colorectal cancer. Dig Dis 2015; 33: 28-37
    CrossrefPubMedSearch in Google Scholar
  • 21 Djinbachian R, Dube AJ, von Renteln D. Optical diagnosis of colorectal polyps: recent developments. Curr Treat Options Gastroenterol 2019; 17: 99-114
    CrossrefPubMedSearch in Google Scholar
  • 22 Picot J, Rose M, Cooper K. et al. Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation. Health Technol Assess 2017; 21: 1-308
    CrossrefPubMedSearch in Google Scholar
  • 23 Kandel P, Werlang ME, Ahn IR. et al. Prophylactic snare tip soft coagulation and its impact on adenoma recurrence after colonic endoscopic mucosal resection. Dig Dis Sci 2019; 64: 3300-3306
    CrossrefPubMedSearch in Google Scholar
  • 24 Lee SP, Sung IK, Kim JH. et al. Risk factors for incomplete polyp resection during colonoscopic polypectomy. Gut Liver 2015; 9: 66-72
    CrossrefPubMedSearch in Google Scholar
  • 25 Heldwein W, Dollhopf M, Rosch T. et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 2005; 37: 1116-1122
    Thieme ConnectPubMedSearch in Google Scholar
  • 26 Brenner H, Chang-Claude J, Rickert A. et al. Risk of colorectal cancer after detection and removal of adenomas at colonoscopy: population-based case–control study. J Clin Oncol 2012; 30: 2969-2976
    CrossrefPubMedSearch in Google Scholar
  • 27 Brenner H, Hoffmeister M, Arndt V. et al. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 2010; 102: 89-95
    CrossrefPubMedSearch in Google Scholar
  • 28 Adler J, Robertson DJ. Interval colorectal cancer after colonoscopy: exploring explanations and solutions. Am J Gastroenterol 2015; 110: 1657-1664
    CrossrefPubMedSearch in Google Scholar
  • 29 Pohl H, Robertson DJ. Colorectal cancers detected after colonoscopy frequently result from missed lesions. Clin Gastroenterol Hepatol 2010; 8: 858-864
    CrossrefPubMedSearch in Google Scholar
  • 30 van Doorn SC, Bastiaansen BA, Thomas-Gibson S. et al. Polypectomy skills of gastroenterology fellows: can we improve them?. Endosc Int Open 2016; 4: E182-E189
    Thieme ConnectPubMedSearch in Google Scholar
  • 31 Duloy AM, Kaltenbach TR, Wood M. et al. Colon polypectomy report card improves polypectomy competency: results of a prospective quality improvement study (with video). Gastrointest Endosc 2019; 89: 1212-1221
    CrossrefPubMedSearch in Google Scholar
  • 32 Gupta S, Bassett P, Man R. et al. Validation of a novel method for assessing competency in polypectomy. Gastrointest Endosc 2012; 75: 568-575
    CrossrefPubMedSearch in Google Scholar
  • 33 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. United European Gastroenterol J 2017; 5: 309-334
    CrossrefPubMedSearch in Google Scholar
  • 34 Holme O, Bretthauer M, Eide TJ. et al. Long-term risk of colorectal cancer in individuals with serrated polyps. Gut 2015; 64: 929-936
    CrossrefPubMedSearch in Google Scholar
  • 35 Vleugels JLA, Hazewinkel Y, Fockens P. et al. Natural history of diminutive and small colorectal polyps: a systematic literature review. Gastrointest Endosc 2017; 85: 1169-1176.e1161
    CrossrefPubMedSearch in Google Scholar